Merieux Foundation7th Vaccine Acceptance Meeting

September 2019

W. Douglas Evans, Ph.D.The George Washington University

wdevans@gwu.edu@douge66

Design and Evaluation of a Branded Narrative Story-based Intervention to Promote HPV Vaccination in Rwanda

mailto:wdevans@gwu.edu

Collaborators

Dwan Kaoukji

Luis G. Espinal

Jon Gower

Emmanuel Hakizimfura

Nicole Barrett

Matthew Freeman

Outline Challenge of promoting HPV vaccination in low and

middle income (LMIC) countries

Health Branding as a Strategy for Behavior Change

Girl Effect branded media platform called Ni Nyampinga (NN) in Rwanda

Efficacy study of NN branding to promote HPV vaccination uptake

Evidence on HPV Vaccination Promotion

Evidence of potential barriers to HPV vaccination promotion (eg, myths, such as promiscuity and infertility)

Most studies on reducing barriers in rich countries (unpublished review)

In LMIC, HPV vaccine recommendation from provider may alleviate parental concerns and influence intent to vaccinate child (Nowak et al., 2015; Paul et al., 2014; Vielot, et al., 2017)

Wamai et al. (2012) evaluated a campaign in Cameroon.

“As part of the campaign strategy…health workers visited…communities, sharing information about HPV and cervical cancer...”

Limited evidence on vaccine promotion suggests need for new efforts

Anatomy of a Brand…

Brand Execution

Brand Personality

Brand Position

Things we decide

Things they experience

• “A brand is a set of

associations linked to a name,

mark, or symbol associated

with a product or service…A

name becomes a brand when

people link it to other things.”

(Calkins 2005, p. 1)

• Behaviors (vaccination?) can

also be branded by creating

mental associations with

beneficial behavioral

outcomes

Positioning behavior – It works!

Published Health Brands (n = 75)

HIV/Safe Sexual

Practices, 11

Diet & Nutrition, 8

Other, 7

Tobacco Control, 23

Skin Cancer Prevention, 4

Physical activity, 12

Drug abuse, 10

• Effect sizes avg d = .12 compared to .05-.09 for all campaigns (Synder et al, 2013)

• Many have large effects up to d = .32

• Wide range of topics, reach• Evans et al, 2015, Trans Behav Med• PROMISING PRACTICE, BUT

NOTHING ON VACCINATION BRANDING

Promoting HPV Vaccination in Rwanda Vaccination mandated for girls in school, government estimates 93%

https://www.cnn.com/2019/05/30/health/rwanda-first-eliminate-cervical-cancer-africa-partner/index.html

However, not all girls are in school, estimates vary

Existing platform for girls’ empowerment, called Ni Nyampinga, represented an opportunity to test a novel approach to HPV vaccination promotion

Uses an indirect, storytelling approach (as opposed to direct messages)

https://www.cnn.com/2019/05/30/health/rwanda-first-eliminate-cervical-cancer-africa-partner/index.html

Ni Nyampinga – Girl Effect’s

most established behavior

change initiative

Launched in 2011 in Rwanda

Multi-platform youth brand that includes a

magazine, a network of clubs and digital

platforms, radio drama and talk show, made by

and for young people.

Ni Nyampinga (NN) has become a nation-wide

movement with 8-in-10 of all Rwandans aware

of it and 55% of people over 10 years old

reading or listening to our products every year

(over 4.3 million people).

9

Ni Nyampinga creates entertaining educational content

addressing the challenges facing girls in Rwanda

Girl Effect addresses both specific issues around

knowledge, attitudes, behaviours and norms across

the domains of health, education, economic

empowerment and safety, alongside broader themes

around confidence and value

“Horizontal” lifestyle brand, not topic specific

Partner with a range of supply side services, NGOs,

implementers and Ministries to provide the most

relevant and of value information to girls.

Kelly and her school mates singing the national anthem

“EVERY STUDENT BROUGHT

ME

AN ISSUE AND I HAD TO DO

SOMETHING ABOUT IT”

FRIENDS ARE LIFE

BY MARLENE MUTIMAWASE

Before concluding the meeting, w

e were

surprised to see the students clap

ping their

hands together. They laughed an

d suddenly

started to make the same signs a

t the same

time. They put their palms on thei

r foreheads,

and then on their chests. One of

the teachers

at the school, Francine, explained

to us that

Kelly and her fellow students we

re singing

“Rwanda Nziza”, the national an

them.

Kelly is 22 years old and in senio

r four at

secondary school, which is also th

e last year

in her vocational educational pro

gramme.

She studies sewing, cooking and

hairdressing.

For Kelly, joining the school was a

revelation

and the first step in realising her

potential.

“Before being part of this schoo

l, I was

always alone,” she says. “I didn’t

have

anyone to talk to, and I used to th

ink I was

the only person who could neither

hear

nor speak. But that all

changed when I came

here because I found

people who have the

same condition as me and

we became friends.”

Kelly says that when

she found friends at

the school, she didn’t

feel lonely anymore;

and they inspired her

to believe she could be

a leader. Ange, Kelly’s

classmate and close

friend, said: “Kelly isn’t

shy and can represent

us well.” Clementine,

another classmate, says

Kelly talks to everyone

and always includes all students.

It was election day when her frie

nds

proposed Kelly as a candidate.

To her

surprise, she was elected as the h

ead

girl of the school! “I was astonish

ed,” she

says, “but my friends calmed me

down

and promised to be there for me

.”

Kelly told us how her friends cont

inue to

support her: “They have been the

re for me

and they helped me to know mys

elf, to build

self-confidence, and they correct

me when

necessary. All in all, I don’t feel a

lone.”

“Every student brought me an iss

ue and I

had to do something about it” sh

e says.

Kelly told Ni Nyampinga that som

etimes she

felt useless and wanted to quit be

cause she

was being asked to solve issues th

at were

beyond her capacity. One of the

issues that

was very difficult was the studen

ts who did

not have a place to go during

holidays. But she went to the

school leaders who supported

her to resolve the problem.

This helped her see that, even

as a leader, it is important

to reach out for support,

especially when you’re unsure

of how to handle a situation.

Today, Kelly must fulfil her

responsibilities as a leader while

at the same time continuing her

studies. She said being a role

model for fellow students has

encouraged her to perform

well. “Before I became head

girl, I was the eighth best

student in my class, but this year

I am the seventh,” she says.

Kelly says she has benefited a lot

from

the experience of being a leader

and that this will help her achiev

e her

goal of working in a hotel: “I lea

rned

perseverance, and I know this wi

ll help

me on my journey to work in a ho

tel.”

Kelly happily said that if it was n

ot for

the support of her friends, she w

ould not

have realised her talents and ab

ilities.

“That is why I think friends are lif

e.”

Talking to Kelly clearly confirms

that disability is not inability.

Being a leader has changed Kell

y’s

life. She has learned to address

people in public and now feels s

he

can do something for her family

and give advice to her younger

siblings. She has no doubt that he

r

behaviour has changed because

she is now a role model for other

people, especially young girls an

d

boys with different disabilities.

The way Kelly has grown as a res

ult

of being a leader has been notice

d by

Brother Fulgence, the principal of

the school.

“Kelly used to be quiet, but since

she

took on these new responsibilities

, she

doesn’t wait to be given orders. S

he finds

the right thing to do and does it h

erself .

She is very responsible,” he said.

Getting elected was not the end

of

Kelly’s leadership journey. She w

as the

first student elected to represent

the

school and she is often overwhelm

ed

by requests from fellow students.

ON THE MORNING WE ARRIV

ED AT A SCHOOL IN HUYE F

OR STUDENTS WHO ARE UN

ABLE

TO SPEAK OR HEAR, WE SA

W A NI NYAMPINGA STAND

ING IN FRONT OF MORE THA

N 150

STUDENTS WEARING YELLO

W AND BLUE UNIFORMS. H

ER LIPS WERE MOVING AND

SHE WAS

USING HER HANDS TO MAKE

SIGNS. THE OTHER STUDENT

S WERE LOOKING INTENTLY

AT HER.

APART FROM SEEING THEM

NODDING AND SIGNING TH

EMSELVES, WE COULDN’T HE

AR A

SOUND. WE BECAME CURIO

US ABOUT THIS AMAZING G

IRL. WHO W AS SHE AND HO

W DID SHE

BECOME SO CONFIDENT? W

ITH ONE OF HER TEA CHERS

TRANSLATING FOR US, WE M

ET KELLY

AND SHE SHARED HOW HER

FRIENDS SUPPORTED HER T

O DREAM BIG AND BECOME

A LEADER.

Kelly hanging out with her friends

11ISSUE 23

10ISSUE 23

OUR VOICE, OUR VALUE

OUR VOICE, OUR VALUE

10

A range of voices and formats

Older Role Models

The ‘Baza Shangazi’ (Ask

Aunty) character answers

questions specifically around

health. For Rwandan girls she is

one of the most trusted sources

of information.

Youth Role Models

NN journalists are 18-24 year

old Rwandan women. They

interview real girls and role

models for magazine and radio

tackling issues through the

voices of girls themselves.

Fictional Characters

The radio drama ‘Ni Nyampinga

Sakwe’ features adolescent girls

and boys. These fictional

characters role model sensitive

and complex issues/experiences.

11

Three phases of research (2017-2018)

Methods

Formative research (focus groups with girls age 9-15)

Prototype test to develop 3 radio messages to promote HPV vaccination among girls age 12-13 who had not yet been vaccinated

Efficacy trial - Randomized 726 girls to 3 groups: 1) NN story telling style (NN branding); 2) unbranded story telling style (no NN), & 3) control condition (public service announcement)

Pre-test survey, exposed girls to their radio spot, and then a followup

Gave each girl an MP3 player with their condition’s radio spots and asked them to listen to them for 2 weeks; re-interviewed girls at post-test

Formative: Differing knowledge/sources of HPV info

Not aware Heard Aware

They have never heard it

● Sisters● Friends● Other people in the

communitySource:

Who: ● Some of girls who have not yet vaccinated and out of school

● Some of mothers

● Radioprogrammes

● Few girls who have not yet vaccinated.

● Some girls who have vaccinated

● Female parents● Some of male parents

● Some of maleparents

Heard

● Teachers

● Some girls havebeen vaccinated

● Few girls who havenot yet been vaccinated.

Formative research lessons learned

1. Girls show positive relationships

with health centres and vaccines

generally and are increasingly

likely to visit health centres with age

(i.e. 13 years cohort). Knowledge

and attitudes towards vaccines in

general are positive.

2. Awareness of the HPV vaccine is

variable, and the majority

understand there are significant

health benefits for girls / women.

Levels of detailed knowledge of the

HPV vaccine (and HPV disease)

can be lower among some girls and

their mothers.

3. Sub-optimal information can

create space for the spreading of

rumours. One commonly cited

belief is that the vaccine will stop

girls from being able to give birth in

the future, and these rumours can

be compounded by anxiety about

the pain of the needle for some.

4. Fathers are likely to have

accurate information, as they

listen to radio, however, they are

less likely to speak with their

daughters about it.

15

Prototype for efficacy test

Unbranded direct (control): 78-seconds audio with direct messaging (PSA style) on how/why to seek out the vaccine.

Branded direct: 77-seconds audio clip, branded as NN with an older female authority (Baza Shangazi) talking directly to the audience, and a direct message to on the importance and the need to vaccinate.

Branded indirect: 88-seconds audio clip with conversation between Baza Shangazi and a female journalist around the vaccine and the health implications, value for girls’ own health

Prototype testing summary results

Indirect style of content delivery was preferred over direct style

Familiar, older female presenter trusted to provide health information and advice

The infertility myth can be countered

Messages can create positive attitudes toward HPV vaccine (and vaccines in general)

Girls respond positively to messages which encourage looking after one’s own health

Possible to talk to girls about HPV virus when presenter trusted and time to explain

Men not viewed as appropriate presenters of HPV vaccine information for girls

Efficacy study objectives

The purpose of the efficacy test was to compare effects of a branded approach at improving the knowledge and attitudes of girls towards the HPV vaccine, when compared to an unbranded approach

Main objective was to understand the added-value of a branded approach to influencing knowledge & attitudes of the HPV vaccine

Top level efficacy findings

Knowledge about HPV both at pre- and post-test was already quite high (most 90% or higher true responses) Scale measured range of facts about the vaccine, including cervical cancer prevention Lowest 71% - ‘You may not notice that you have the HPV in your body’ at pre-test Most common place to have heard about HPV – radio 52% Most common place to have heard about HPV vaccine – health worker 56%

Media use Radio highest (53% daily) TV second (25% daily) Low social media use (Facebook 23% among those with Internet, 2.2% total)

Models: Knowledge of HPV vaccinationKnowledge Continuous outcome (no influencers removal)

Knowledge Continuous outcome (removing influencers observations)

Knowledge of preventive medicine (single item, imputed values)

Knowledge of preventive medicine (single item, only valid responses)

Branded/Direct 0.0125 -0.0029 0.4516 0.4832

Branded/Indirect 0.0119 -0.00624 -0.059 -0.177

Post-stimulus effect (net effect)

0.0881*** 0.08974*** 1.44*** 0.621*

Branded/Direct at post post-stimulus (treatment effect)

0.0090 0.0310 -0.183 0.146

Branded/Indirect at post post-stimulus (treatment effect)

0.0207 0.0339* 0.863* 1.383**

# Observations 1668 1410 1668 1025

Control variables: Income level, Access to media, Prior awareness of NN, family size

Branded indirect group follow upSelf-reported dosage during at post-test

Time Audio Device Played Freq. Percent Cum %

Only once 4 1.41 1.41

2 to 3 times 28 9.89 11.31

4 to 6 times 88 31.1 42.4

More than 6 times 161 56.89 99.29

Don’t know 2 0.71 100

Total 283 100

• Variability in self-reported frequency of exposure to messages.

Dose-response effects on vaccine attitudes There was a positive effect of higher dosage on attitudes about the efficacy/safety of

the HPV vaccine (dose-response) in two models (attitudes more positive in both)

Vaccine not effective Worry about side effects

Time Audio Device Played (1

level increase) 0.0343*

0.157*

95% confidence intervals [0.00182,0.0668] [0.0236,0.289]

P-Value (0.039) (0.037)

N 281 281

Vaccine not effective Worry about side effects

More than 6 times

vs. other (ref) 0.0536*

0.2364*

95% confidence

intervals [0.00356,0.104] [0.0346, 0.4383]

P-Value (0.041) (0.022)

N 281 281

Overall Findings from Efficacy Study

Significant treatment effect of the branded indirect upon levels of knowledge (overall scale), compared to the control

Significant treatment effect of the branded indirect upon levels of knowledge (single item about effectiveness of HPV vaccine as preventive medicine for cervical cancer)

Dose response effect of brand indirect messages on attitudes toward HPV efficacy/safety

Discussion/limitations

HPV vaccine knowledge/attitudes can be changed by exposure to NN branded messages

Conclusions should be drawn with caution as the test was brief, exposure was limited, in single channel, and format was new and untested

There are several factors to consider in future research

Intensity/duration of treatment

WHO says WHAT message to WHOM…WHEN and WHERE?

Channels relative to audience/location

Health seeking behavior : Demonstrate a low-cost demand model

The biggest cost driver for HPV vaccination programmes = cost of vaccine distribution to remote locations

Cost is substantially reduced in a health facility-based delivery setting, but challenge is to get girls to the facility

Improving health-seeking behavior has relevance & importance beyond HPV and vaccinations

Supporting individual health seeking behavior can drive demand for a broad range of adolescent services

Potential for a sustainable model in adolescent health, and not just HPV/immunization

HPV vaccine

Other vaccines

Nutrition services

SRH services

HIV services

Health Facility

Girls

Thank you! Questions?

wdevans@gwu.edu

@douge66

mailto:wdevans@gwu.edu